Introduction
Factors such as scientific and technological advances, early diagnoses, application of new treat- ment methods, increases in healthcare precautions, and supporting healthy lifestyles have all re- sulted in an increase in the elderly population worldwide (1). Global statistics show that the world population is constantly increasing. It is expected that by 2020, 35 million people will be aged
>65 years and 7 million people will be aged >85 years in the United States of America. In 2009, 13.14% of the world population was aged >65 years, which will be 22.4% in 2041 (1, 2). According to data from the Turkish Statistical Institute (2013), the percentage of the elderly population in Turkey will be 10.2% in the year 2023, and Turkey will be classified as a country with a “very old”
population (3). However, according to the 2011 census in the Turkish Republic of Northern Cyprus, the number of people aged >65 years was 21, 615, and the percentage of the elderly was 12%
(4). The term ageism, meaning discrimination of the elderly, was first coined in 1969 by Robert Butler, head of the American National Institute of Old Age. He described the discrimination of the elderly as a type of ideology that can easily develop into actions such as gender and racial dis- crimination. In contrast, Palmore described it as a term that expressed prejudices, attitudes, and behaviors against the elderly (5). According to Vefikuluçay (6), the discrimination of the elderly is a multidimensional factor, which includes different attitudes, prejudices, behaviors, and actions against somebody only because of their old age.
The sociocultural structure of the society, fluctuations in its behavior and attitude, and individual and societal perceptions of the elderly have impacted the services offered to the elderly. The discrimination against the elderly also has a negative effect on elderly care (1). Elderly care re- quires interdisciplinary teamwork, and the importance of a nurse in the team is certain. Thus, the perception of nursing students is important (7). In a study conducted by Gözüm and Tan (8) to determine the knowledge and practice of healthcare providers in terms of the care given to the elderly, it was observed that doctors provided the highest level of healthcare to the elderly (8). In the study conducted by Karlin et al. (9), which included psychology and nursing students, it was
Opinions of the Nursing Students on Ageism
Objective: To determine the opinions of nursing students on ageism and their thoughts regarding working with elderly individuals after gradu- ation.
Methods: This descriptive study was conducted in the academic year 2014–2015 and included 175 student volunteers, of whom 114 were first- grade students and 61 were fourth-grade students studying in the Nursing Department, School of Health Sciences, Near East University. The Personal Information Form and Ageism Attitude Scale (AAS) were used for collecting data, which were assessed using the SPSS 20.0 statistics package program (Statistical Package of Social Sciences, v. 20.0 Chicago, IL, USA). The chi-square test was used for cross tables, and the t-test was used for comparing two-choice questions of the scale in the independent groups; single direction variance analysis was used for analyzing variables with more than one choice.
Results: The attitudes of students in terms of elderly discrimination were positive, and the average AAS score was 79.56±9.39. The average total AAS score and average total score of the “negative discrimination against the elderly” sub-scale of the first-grade students were lower than those of the fourth-grade students (p<0.05). For all students, a statistically significant difference (p<0.05) was determined between the “working with the elderly individual” status and the “negative discrimination against the elderly” sub-scale. For all students, a statistically significant difference was determined between the “living with parents in the future” status and the “working with the elderly in the future” status (p<0.05).
Conclusion: Nursing students have a positive attitude toward elderly discrimination. The data suggests that, during their last academic year, nursing students should be educated about attitudes toward the elderly, and they should be given the opportunity to work with elderly indi- viduals.
Keywords: Student nurse, elderly, elderly discrimination, attitude scale
Abstr act
Department of Nursing, Near East University School of Health Sciences, Turkish Republic of Northern Cyprus
Address for Correspondence:
Ümran Dal Yılmaz
E-mail: umrandal65@gmail.com Received:
29.04.2016 Accepted:
19.10.2016
© Copyright 2017 by Available online at www.istanbulmedicaljournal.org
DOI: 10.5152/imj.2017.02997
Tülay Demiray, Ümran Dal Yılmaz
observed that both student groups had positive attitudes toward the elderly; however, it was later observed that psychology stu- dents had a stronger preference for working with the elderly than nursing students (9). Molye (10) determined that nursery education students did not want to work with the elderly and had a negative discrimination attitude. Shen (11) determined that geriatric clinics were the second-least preferred institutions by nursery education students after graduation.
The increasing population of the elderly in Turkey and worldwide requires that nurses in the healthcare system work with the el- derly. A number of studies have been conducted regarding ageism in various countries, including ours. The studies aimed to examine the attitudes of nursing students concerning ageism and elderly discrimination and to provide a context based on the training pro- vided for elderly care to increase awareness (7, 12-14).
Improvements in the elderly care education of nursing stu- dents are necessary, and government policies and healthcare standards need to be developed and organized. Studies, prob- lem-solving exercises, and empathy sessions with the faculty of medicine students regarding geriatric modules have been performed, with positive results (15). It is important that the education and training given to nursing/nursery education students include more programs regarding the elderly (11, 16). This study was planned and conducted to determine the opinions of first- and fourth-grade students, studying in nurs- ery education departments, about discrimination against the elderly and their inclination to work with elderly individuals after they graduated.
Methods
This descriptive study included students studying in the Nursery Education Department of the School of Health Sciences of Near East University in the 2014–2015 academic year. Of 175 student volunteers, 114 were first-grade students and 61 were fourth-grade students. The Personal Information Form and Ageism Attitude Scale (AAS), prepared by the researchers on the basis of the litera- ture, were used for data collection (1, 5, 6, 8-10).
The Personal Information Form comprises questions regarding so- ciodemographic information of elderly/old age individuals.
Ageism Attitude Scale comprises 23 items and three dimensions (limiting the life of the elderly, positive discrimination against the elderly, and negative discrimination against the elderly). Ve- fikuluçay and Terzioğlu determined that there was a statistically significant association among all the AAS items (p<0.01) and that the internal consistency coefficient (Cronbach’s coefficient) of AAS was 0.80.
The scale is valid and reliable for the desired level in terms of de- termining discrimination against the elderly attitudes of university students, and it could be used in other studies. AAS is a 5-point Likert Scale that has choices such as “I do not agree at all,” “I do not agree,” “I am indecisive,” “I agree,” and “I totally agree,” and it has positive and negative attitude statements. The positive attitude statements are given scores of 5=I totally agree, 4=I agree, 3=I am indecisive, 2=I do not agree, and 1=I do not agree at all. The nega-
maximum score that can be obtained is 115, and the minimum score is 23. Higher scores indicate a more positive attitude toward discrimination. AAS comprises three dimensions as follows:
• Limiting the life of the elderly: The beliefs and perceptions of the society in terms of limiting the social life of the el- derly. The maximum score that can be obtained from this dimension is 45, and the minimum score is 9.
• Positive discrimination against the elderly: Positive beliefs and perceptions of the society in terms of the elderly. The maximum score that can be obtained from this dimension is 40, and the minimum score is 8.
• Negative discrimination against the elderly: Negative beliefs and perceptions of the society in terms of the elderly. The maximum score that can be obtained from this dimension is 30, and the minimum score is 6 (Vefikuluçay, Yılmaz, and Terzioğlu; 2011).
Study Limitations: The study has been conducted only with first- and fourth-grader students studying at nursing departments.
A study conducted with students from all grades would provide more generalizable results.
Ethical Considerations: Before initiating the study, written ap- proval was obtained from the relevant institution. Moreover, par- ticipating students were told the study purpose, and oral consent was obtained.
Statistics analysis
The Statistical Package of Social Sciences v.20.0 software (SPSS Inc.;
Chicago, IL, USA) was used for assessing the data. The chi-square test was used for cross tables. The t-test was used for comparing the scale with two-choice questions. One-way analysis of variance was used for variables that had more than two choices. P values of
<0.05 were considered to be statistically significant.
Results
It was determined that 77.7% of the participating nursing stu- dents were females, 52% were aged between 20 and 22 years, 97.1% were single, 65.1% were first-grade, 40% lived in the city for the longest duration, and 73.7% had an elementary family structure (Table 1).
When the grades of the students were considered, it was observed that the average total AAS score of the first-grade students was sig- nificantly lower than that of the fourth-grade students (p<0.05).
Furthermore, the average score of the “negative attitudes against the elderly” sub-scale of first-grade students was lower than that of fourth-grade students (p<0.05; Table 1).
During nursing practices, a significant difference was determined between the average “negative discrimination against the elderly”
sub-scale score of students who worked with the elderly and those who did not (p<0.05; Table 1).
The average total AAS score was 79.56±9.39. The average total score of the “limiting the life of the elderly” sub-scale was 33.47±4.46, that of the “positive discrimination against the elderly” sub-scale was 28.91±5.28, and that of the “negative discrimination against
8
Table 1. Sociodemographic characteristics of the students and the distribution of AAS scores (n=175)
Limiting the life Positive discrimination Negative discrimination
Variables N of the elderly against the elderly against the elderly AAS total scores
Sex
Female 136 33.80±4.28 28.82±4.79 17.14±3.18 79.76±8.59
Male 39 33±4.91 29.26±6.79 17.28±3.98 78.87±11.87
t=1.826 p=0.070 t=-0.458 p=0.647 t=-0.233 p=0.816 t=0.518 p=0.605
Age, y
Between 18 and 20 42 33.43±4.45 28.07±5.64 16.74±3.40 78.24±9.29
Between 21 and 22 91 33.25±4.55 28.85±5.55 17.02±3.44 79.12±10.06
23 and over 42 33.90±4.39 29.57±4.12 18.00±3.05 81.48±7.89
F=0.307 p=0.736 F=0.853 p=0.428 F=1.732 p=0.180 F=1.380 p=0.254
Marital Status
Married 5 35.20±2.59 28.80±7.19 17.00±4.00 81.00±7.38
Single 170 33.45±4.51 28.85±5.23 17.15±3.34 79.44±9.48
t=-0.863 p=0.389 t=0.019 p=0.958 t=0.098 p=0.922 t=-0.364 p=0.716
Grade
First grade 114 33.22±4.42 28.80±5.63 16.71±3.69 78.73±9.95
Fourth grade 61 34.23±4.23 25.30±4.48 18.03±2.51 81.56±7.70
t=-1.451 p=0.149 t=0.588 p=0.557 t=-2.51 p=0.013 t=-2.074 p=0.040
Lived in the place for the longest duration
Village 42 32.98±4.90 27.64±6.31 17.19±3.33 77.81±10.30
County 63 33.57±4.67 29.40±5.01 16.84±3.73 79.81±9.42
City 70 33.68±4.00 29.13±4.78 17.35±2.99 80.16±8.79
F=0.344 p=0.709 F=1.538 p=0.218 F=0.389 p=0.678 F=0.879 p=0.417
Family type
Elementary 129 33.60±4.29 28.83±5.09 17.16±3.29 79.59±9.01
Extended 43 33.42±4.33 29.58±5.40 17.16±3.58 80.16±9.49
Broken 3 28.67±11.02 23.00±9.54 18.00±4.36 69.67±20.82
F=1.822 p=0.165 F=2.276 p=0.106 F=0.092 p=0.912 F=1.770 p=1.770
Mother’s profession
Housewife 135 33.60±4.39 28.94±5.22 17.18±3.23 79.72±9.15
Official 8 29.63±7.21 30.13±7.59 18.50±2.20 78.25±13.30
Employee 15 33.27±3.33 26.20±5.13 16.33±3.35 75.80±8.83
Retired 9 35.67±3.84 30.89±4.14 17.56±5.05 84.11±10.01
Other 8 34.00±2.62 30.50±4.31 16.75±4.68 81.25±8.94
F=2.167 p=0.075 F=1.609 p=0.174 F=0.598 p=0.665 F=1.248 p=0.293
Father’s profession
Does not work 7 32.43±5.47 30.14±4.78 17.71±4.86 80.29±11.51
Employee 37 33.68±3.42 27.84±3.91 17.11±3.11 78.62±7.36
Official 36 32.75±5.76 30.03±5.43 17.25±2.90 80.03±10.57
Retired 53 34.08±3.77 29.77±5.21 17.21±3.48 81.06±8.82
Farmer 14 33.93±3.02 29.64±3.18 16.57±3.37 80.14±6.44
Other 28 32.82±5.24 26.96±6.90 17.11±3.82 76.89±11.87
F=0.617 p=0.687 F=1.856 p=0.105 F=0.131 p=0.985 F=0.818 p=0.538
Have you ever worked with the elderly
Yes 62 33.63±4.66 29.06±4.76 18.03±2.98 80.73±8.94
No 173 33.34±4.41 28.74±5.58 16.79±3.43 78.87±9.64
t=0.404 p=0.687 t=0.381 p=0.704 t=2.384 p=0.018 t=1.241 p=0.216
Do you want to work with the elderly in the future?
Yes 136 33.60±4.44 29.01±5.34 17.22±3.53 79.83±9.42
No 39 32.92±4.57 28.67±5.18 16.97±2.74 78.56±9.36
t=0.838 p=0.403 t=0.353 p=0.725 t=0.395 p=0.694 t=0.739 p=0.461
t: t-test; F: ANOVA; AAS; Ageism Attitude Scale
9
Moreover, 88% of students who wanted to work with the elderly in the future wanted their parents to live with them, and 71.8% of students who did not want to work with the elderly in the future wanted their parents to live with them. A significant difference was identified between the desire for living with parents in the future and the desire for working with the elderly in the future (p<0.05;
Table 3).
Discussion
The changing sociocultural structure of society, changes in its atti- tudes and behaviors, and perception of individuals and the society toward the elderly affect the services provided to the elderly, and they can produce several problems (5). The elderly face various prejudices in different areas of social life and also experience dis- crimination. The elderly face discrimination in areas such business involvement, intolerance accusations, and social weakness (1).
When sex and average total AAS scores of the students were com- pared, no significant differences were identified between male and female students (p>0.05). In studies by Fitzgerald et al. (17), Lambrinou et al. (18), and Söderhamn et al. (19), it was deter- mined that the attitudes of female students toward the elderly were more positive than that of male students (17-19). In contrast, in the studies of Adıbelli et al. (7), Uysal et al. (20), and Hweidiet al. (21), it was observed that male students had a more positive at- titude than female students. Our study results are consistent with those reported by Vefikuluçay (6) and Soyuer et al. (22). These re- sults may be correlated with the decrease in sex discrimination, with deviation traditional sex roles, and with raising both sexes with the same cultural norms.
In our study, no statistically significant differences were deter-
ever, in the studies of Adıbelli et al. (7), Söderhamn et al. (19), Uysal et al. (20), Soyuer et al. (22), and Hughes et al. (23), it was determined that as the students aged, their attitudes toward the elderly changed. In the studies of Shen (11) and Lambrinou et al.
(18), it was determined that students aged <20 years had positive attitudes toward the elderly. We can reconcile the findings of our study with the fact that the age ranges are close to each other herein.
No statistically significant differences were determined between the average total AAS scores and the most-lived places of the stu- dents (p>0.05). Our findings support the findings of Soyuer et al.
(22) and Yılmaz and Özkan (24). This finding leads us to believe that Turkish society generally considers the elderly from the same point of view.
It was determined that 73.7% of the students had elementary family structures, and no significant differences were determined between family type and average total AAS score (p>0.05). In the study conducted by Yılmaz and Özkan (24), it was determined that students with an elementary family type had higher AAS scores and average sub-scale scores. We currently consider the absence of negative discrimination against the elderly as a positive result, although there is modernization in all aspects of the social life and there is an increase in the number of broken families; we can correlate this situation with the respect for the elderly being con- sidered as a cultural norm.
When the grades of the students were considered, the average to- tal AAS score of first-grade students was significantly lower than that of fourth-grade students (p<0.05). Furthermore, a significant difference was found between the fourth- and first-grade students in terms of average “negative discrimination against the elderly”
Table 2. Minimum and maximum scores of AAS and its sub-scales (n=175)
AAS and its sub-scales n Minimum Maximum Arithmetic Average Std. Deviation
Limiting his/her life 175 17 40 33.47 4.46
Positive discrimination against the elderly 175 10 37 28.91 5.28
Negative discrimination against the elderly 175 9 29 17.17 3.36
Total AAS scores 175 48 104 79.56 9.39
AAS: Ageism Attitude Scale
Table 3. Comparison of the status of the students’ desires of “living with their parents in the future” and their desires of “working with the elderly in the future” (n=175)
Do you want to work with an Status of the desires of “living with parents in the elderly in the future?
future”/desires of “working with the elderly in the future” Yes No Total
Do you want your parents Yes n 120 28 148
to live with you in the future? % 88.2 71.8 81
No n 16 11 27
% 11.8 28.2 19
Total n 136 39 175
% 100.0 100.0 100.0
χ2=5.962; p=0.017
10
Lambrinou et al. (18), Uysal et al. (20), Hweidi et al. (21), Hughes et al. (23), Yılmaz and Özkan (24), and Güven et al. (25), a significant difference was determined between the average total AAS score and the sub-scale scores with respect to the students grades. The negative attitudes of the fourth-grade students were lower than those of the first-grade students (6, 18, 20, 21, 23-25). The fact that the average total AAS score was higher may be correlated with the fourth-grade students having positive attitudes toward the elderly, their working hours with the elderly being greater, and their adop- tion of the notion of individual equality in nursing practices. These items may also indicate that discriminative attitudes decrease dur- ing nursing education and training practices.
It was determined that the mothers of 76.5% of students were housewives, and the fathers of 29.7% of students were retired;
no significant differences were determined between the average total AAS score and the average sub-scale scores in terms of the professions of the mothers and fathers (p>0.05). In the studies conducted by Vefikuluçay (6) and Yılmaz and Özkan (24), it was determined that as lower education levels of the parents yielded a higher average total AAS score and more positive attitudes toward the elderly. These findings, as well as our findings, show that edu- cation does not affect the point of view in our society about the elderly.
During the nursing practices, it was determined that the average total “negative discrimination against the elderly” score of the stu- dents who worked with the elderly were significantly higher than that of the students who did not (p<0.05). In a study by Arnold et al. (15) with two stages of training provided for the students, it was determined that the attitudes of the students changed. Therefore, it can be suggested that education and training regarding the el- derly and working with the elderly positively affects the attitudes of the students. The study results reported by Adıbelli et al. (7), Söderhamn et al. (19), Altay and Aydın (26), and McLaffery et al.
(27) support our study results. We consider that the positive at- titudes of the students who work with the elderly result from their education, training, and the positive attitudes of the active nurses functioning as role models for them.
When the average total AAS scores of the students who studied at the nursing departments were considered, it was observed that their attitudes about ageism were positive (Table 2). In the stud- ies of Vefikuluçay (6), Soyuer et al. (22), Yılmaz and Özkan (24), Altay and Aydın (26), and Kulakçı (28), it was determined that the students had positive attitudes toward the elderly. This result may be because of the respect for the elderly that stems from their cultural values and because positive attitudes toward the elderly are traditional in Turkish society. It is pleasant to see that the increase in the quality of elderly care, the decrease in the negative effect of elderly discrimination to the elderly care were positive.
Moreover, 88% of students who wanted to work with the elderly in the future wanted their parents to live with them, and 71.8% of students who did not want to work with the elderly in the future wanted their parents to live with them. A significant difference was determined between the desire of living with the parents in the future status and the desire of working with the elderly in the fu-
ture status (p<0.05; Table 3). In the studies conducted by Yılmaz and Özkan (24) and Kulakçı (28), it was determined that students who wanted to live with their parents in the future had positive attitudes toward the elderly. In a study conducted by Güven et al.
(25), similar results were determined, and it was also found that the average total score of the negative discrimination against the elderly sub-scale was low. Vefikuluçay (6) did not find a statisti- cally significant difference between the living with the parents in the future status and AAS score. Molye (10) and Gallaher et al. (29) determined that nursing students did not want to work with the elderly after graduation and had negative attitudes.
In our study, the percentage of students who wanted to work with the elderly in the future and who wanted their parents live with them was high. This result suggests that students with positive attitudes toward the elderly will also reflect this attitude in their working lives.
Conclusion
In conclusion, it was determined that first- and fourth-grade stu- dents of the nursing education departments have high AAS scores and high average sub-scale scores, and they also have positive at- titudes toward the elderly. No statistically significant result was obtained when the sociodemographic data of the students and their families were examined (p>0.05). When sub-scale and aver- age total AAS score was considered, the attitudes of the students who worked with the elderly during nursing practices changed with training (p<0.05). Thus, students who wanted to live with their parents in the future also wanted to work with the elderly (p<0.05).
The following items are suggested by the data obtained in this study.
• Topics about the elderly should be included in more detail in the curricula of the nursery education departments, and student should be given the opportunity to work with the elderly during their practical trainings.
• Educational modules about the elderly, in terms of physi- cal care and psychosocial aspects, should be prepared for nursery education students during and after their academic studies and as part of their in-service training.
• Nursery education students should be given information about possible work places where they can work with the elderly after they graduate, and nursery education students should be trained for physical care of the elderly using ho- listic approaches.
Ethics Committee Approval: Ethics committee approval was received for this study.
Informed Consent: Informed consent was obtained from patients who participated in this study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - T.D., Ü.D.Y.; Design - T.D., Ü.D.Y.; Super- vision - Ü.D.Y.; Data Collection and/or Processing - T.D.; Analysis and/or Interpretation - T.D.; Literature Review - T.D., Ü.D.Y.; Writing - T.D., Ü.D.Y.;
Critical Review - Ü.D.Y.
11
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
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